COVID-19 Update April 12, 2020

This blog post is based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.

Proning instructions for patients from New York City

Example of proning instructions for awake patients. Care must be taken to avoid dislodgement of oxygenation therapies, monitors and IVs. This example is for educational purposes only. Follow your hospital-based protocols.

Anticoagulation for COVID-19 patients who are admitted to hospital

Prothrombosis is one of the many not-yet-understood but repeatedly observed aspects of COVID-19. Many hospitals are using aggressive anticoagulation algorithms based on trending D-dimers. At a minimum, everyone admitted should probably be prophylaxed to prevent thrombosis with the following exceptions: active bleeding or platelet count < 25,ooo.

A single center retrospective study of 81 ICU patients with COVID-19 found that a D-dimer >1,500 ng/ml had an 85% sensitivity and 89% specificity for predicting PE, however because of the weaknesses of this study, a D-dimer cutoff should not be used alone to make anticoagulation decisions.

Example of anticoagulation decision algorithm for COVID-19. This algorithm is based on expert opinion and is for educational purposes only. In clinical practice, follow your hospital-based protocols.

A rapid dissemination summary report of a facilitated ‘Knowledge Sharing Session’ between UK clinicians with considerable experience of ICU management of COVID-19 infected patients by the Intensive Care Society as part of the National Emergency Critical Care Committee.

Early aggressive ventilation may adversely affect outcomes

Aggressive ventilation in the early phase may adversely affect later outcomes. The starting PEEP and tidal volumes should be lower than previously recommended; PEEP=10 appears satisfactory for many.

Proning patients should be considered early, to support the vasculature

Proning on admission if in early phase (predominantly perfusion) can be done irrespective of PF ratio, and if response is +ve, this may avoid aggressive ventilation

Using nitric oxide in early stages – it can help but may become refractory after 96 hours

Published findings from the 2004 SARS-CoV infection suggest the potential role of inhaled nitric oxide as a supportive measure for treating infection in patients with pulmonary complications. Treatment with iNO reversed pulmonary hypertension, improved severe hypoxia, and shortened the length of ventilatory support compared with matched control patients with SARS.

A phase 2 study of iNO is underway in patients with COVID-19 with the goal of preventing disease progression in those with severe ARDS. The Society of Critical Care Medicine recommends against the routine use of iNO in patients with COVID-19 pneumonia. Instead, they suggest a trial only in mechanically ventilated patients with severe ARDS and hypoxemia despite other rescue strategies. The cost of iNO is reported as exceeding $100/hour.

Severe upper airway swelling in some patients may make intubation and extubation difficult

Antibiotic usage should be judicious. There are some reports of subsequent aspergillosis and candida infections.

Stopping antibiotics in COVID patients unless clearly indicated, using procalcitonin (PCT) and other inflammatory markers to monitor for bacterial infection and restarting as required*

Using procalcitonin as a ‘stop’ signal to guide when to stop antibiotic use**False negative PCTs seem less of an issue than false positives in determining antibiotic use – anecdotally, rising procalcitonin has also been seen in patients without evidence of bacterial infection, perhaps in relation to ‘cytokine storm’, and so a low PCT may be more helpful (true negative) than a high PCT (false positive)

Renal failure, fluid balance and PEEP

Renal failure has been more common in UK cases than anticipated (20-35% of ICU patients). Careful attention to adequate hydration, and use of lower PEEP, may help.

While many experts have been advocating for judicious fluid administration and avoidance of hypervolemia, hypovolemia may contribute to renal failure.

Pain control may help oxygenation in “happy hypoxic” COVID patients

In patients who are hypoxic, dyspneic and who have chest pain, but are not tiring with CO2 in the 20’s, consider pain control with a combination of NSAIDs and acetaminophen and/or low dose ketamine. Anecdotal evidence suggest that adequate pain control may improve oxygenation.

Andrew Morris COVID-19 Update April 12th, 2020

Diagnosis — we still don’t know the sensitivity nor specificity of the PCR test. There is an emerging challenge around what IS COVID-19 disease: for example, we are seeing case reports of antiphospholipid antibody syndrome/hyprecoaguability (Zhang Y, Xiao M, Zhang S, Xia P, Cao W, Jiang W, et al. Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. N Engl J Med. 2020; https://www.sciencedirect.com/science/article/pii/S0049384820301201) and neurological outcomes (Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurology. 2020). We will continue to see this over time: everyone will come up with a case series of biochemical abnormalities, GI abnormalities, psychiatric abnormalities, etc. which are not helpful: as the disease becomes more prevalent—and as we recognize the phenomenon of asymptomatic disease—one starts to see the challenge of identifying what is baseline presence of difference symptoms/signs/complications, vs. COVID-attributable disease. Additionally, people will make preventative therapeutic recommendations based on responding to observational data, which is not advisable.

Medical treatment — the real emerging concern is that the public are getting information that (to the uninformed) appears to be encouraging: great outcomes with patients on HCQ + azithromycin (https://t.co/mTWj6aGpTk?amp=1) or remdesivir (Grein J, Ohmagari N, Shin D, Diaz G, Asperges E, Castagna A, et al. Compassionate Use of Remdesivir for Patients with Severe Covid-19. New England Journal of Medicine. 2020). But these studies are so flawed as to be useless. Fortunately, there are numerous clinical trials out there that will help answer some of these questions very quickly, with some results expected in the next 5-10 days! Unfortunately, almost everyone is studying the same drugs So we will have wasted tremendous opportunity and research capacity by not considering different paradigms—and so many trials include HCQ, that it may be very difficult to tease out if it even makes a difference. I hope we get that answer soon.

Prognosis — still very uncertain. Global fatality rate ~7%, but it is so sensitive to the denominator (i.e. What is a case?) that populations with plenty of screening tests will have a lower case fatality rate than those with lower screening tests. Additionally, there is emerging information from the UK that getting into the ICU with COVID is pretty bad (https://www.icnarc.org/About/Latest-News/2020/04/10/Report-On-3883-Patients-Critically-Ill-With-Covid-19) It is always difficult to know if what is going on in a different country or jurisdiction is entirely the same as yours, but I think the UK experience probably translates pretty well to the Canadian experience. I think the most important figure in the whole document is Figure 9, which shows that there is an early bias favouring mortality (i.e. suggesting high mortality), that diminishes over time, as we see more people surviving longer stays in the ICU. This is a testimony to good ICU care. It still ends up with a 50% mortality, though, which ain’t great. I also want to highlight how this comes from a reasonably healthy population.

ACOG COVID-19 algorithm assessment and management of pregnant patient

A cognitive aid for the pandemic airway: the basics of how to increase safety and team cohesion during intubation, donning, and doffing

By PG Brindley, JM Mosier, CM Hicks

Viruses such as the SARS-CoV-2, which causes covid-19, can be associated with performance-retarding anxiety and information-overload; especially for those performing stressful procedures like intubation, and especially if there are unfamiliar steps. We offer this simple airway-management mnemonic/checklist/cognitive-aid that utilizes the five letters: C.O.V.I.D. Our goal is to allay fears, expedite action, decrease viral spread, and highlight what has changed. This aide-memoire can also be used for future highly infectious aerosol generating viruses, or whenever enhanced PPE is required. After all, we need to protect our staff, as well as patients, now and always; and other infectious pandemics are predicted.

An easy to remember cognitive aid may help because it can enhance shared mental models (especially if personal protective equipment (PPE) impairs communication), maintain cognitive bandwidth (via a common aide-memoire), increase safety (by decreasing time in infected rooms, increasing first-pass success, and optimizing donning and doffing technique) and make it routine to cross-monitor team members using ‘buddy checks’.

Even without COVID-19, airway management is more dangerous and complex when performed away from Operating Rooms, or if it includes unfamiliar staff (1). Cognitive aids with fewer than seven steps, and those that ask questions (i.e. “what will you do, and when”) appear to be superior to those that are long or passive (2). Moreover, checklists should facilitate safe teamwork not just individual taskwork (3).

In the case of highly infectious diseases such as COVID-19, safety requires undoing years of muscle memory (e.g. avoiding bagging, high flows, etc to prevent aerosolization). To date, much of the work on airway management has focused on the anatomical difficult airway, or the physiologically difficult airway (i.e. low blood pressure, right ventricular pathology) (4). While both are important, pandemics require increased attention to situational difficulty (personal fear, situational unfamiliarity) (1-5). Because of the increased need for coordination, role clarity, and shared safety, we offer a 5-step acronym using five unforgettable letters.

Step 1: C-

Coordinate who will do what and when. Perform a pre-brief (3) where roles are assigned before entering the room, and assign “buddies” to check that PPEs offer body coverage

Collect all equipment at bedside, so that you do not have to doff and leave room.

Colleague outside of the room. Available to help if needed and already wearing PPE.

Step 2: O-

Only have three people in the room and use most experienced intubator and techniques that increase first pass success (i.e. full-dose paralysis).

Outside the room until your PPE has been checked by your buddy, and negative pressure turned on (if available).

Obstruct the ETT with a clamp prior to connecting the ventilator

Step 3: V-

Videolaryngoscopy is preferable to decrease intubator’s exposure to aerosols.

Voice communication with those outside the room (activate a microphone or walkie-talkie)

Verify tube placement with ETC02 and that the ETT cuff is inflated before initiating positive pressure breaths.

Step 4: I:

Inflate the endotracheal tube cuff prior to bagging or placement on the ventilator.

Interrupt the circuit as infrequently as possible and only at end expiration.

Insert a supraglottic airway rather than using vigorous bag-mask ventilation.

Don’t leave the room prematurely i.e. before your buddy has given the “okay”.

While this mnemonic has not been tested empirically, it received iterative multi-professional input (MD, RN, RT) and multidisciplinary input (Critical Care, Emergency Medicine, Anesthesia). It was finessed during 10 drafts and over 20 iterative high fidelity mannikin simulations, and until no further changes were requested. It was deemed robust enough to serve throughout the hospital, and to benefit all members of the airway team. It was associated with an increased in subjective team cohesion and interdisciplinary esprit de corps. It was also associated with individual and shared safety: regardless of one’s specialty or role.

“We suggest it may be reasonable for healthcare providers to consider defibrillation before donning personal protective equipment for aerosol generating procedures in situations where the provider assesses the benefits may exceed the risks (good practice statement).”

“Given the potential for defibrillation within the first few minutes of cardiac arrest to achieve a sustained return of spontaneous circulation and uncertainty of the likelihood of defibrillation generating an aerosol, we suggest healthcare providers consider the risks versus benefits of attempting defibrillation prior to donning personal protective equipment for aerosol generating procedures.”

“Once [PPE is]donned we identified evidence that there is a risk of mask slippage during chest compression delivery rendering the protective equipment less effective.”

“The practical implementation of these recommendations will require regional and national resuscitation councils to consider the values and preferences of their local communities, the prevalence of disease, availability of PPE, training needs of their workforce and infrastructure / resources to provide on-going care for patients resuscitated from cardiac arrest.”

This blog post is based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.

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